**2. Factors influencing EPI implementation**

The information gleaned from the peer-reviewed articles, government reports, EPI documents, WHO/UNICEF/GAVI reports and some gray literature, unravels a stagnant or declining immunization status. At the same time, this analysis also shows a multifactorial picture responsible for the current state of affairs of EPI in Pakistan.

**2.3. Human resource**

**2.4. Service delivery**

the private sector [13].

power outages.

**2.5. Supplies and vaccines**

The lack of a comprehensive human resource (HR) strategy has been discussed time and again in the context of EPI in Pakistan. There is no regular and formal training program for the management cadres, and learning is mostly self-directed and on the job. Managers often lack the practical knowledge for leading program operations proficiently [19]. EPI workers' fatigue due to frequent polio campaigns have reduced their time dedicated to routine EPI vaccination initiatives [13]. In-service training for routine immunization staff is not held on the basis of any planning and programming, rather it is conducted whenever the donor funding is available. Competency of the staff, outreach capacity, service structure, attitudes toward clients, political interference in transfers and postings, and lack of accountability are all notable HR related issues of EPI [20, 21]. On the other hand, there are workers in the Polio program who are willing to perform their duties while putting their lives at risk, and facing extremist sections of the society, amidst a grim law and order situation [22]. Introducing incentive structures among managers and health workers of EPI or contracting with non-governmental

Implementation of the Expanded Program on Immunization (EPI): Understanding the Enablers…

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Immunization services provided through outreach are costly and face logistic issues. The outreach strategy of EPI lacks details in micro-plans; has weak monitoring and supervision; and deficient human, operational, and other resources [13]. In many rural areas, routine immunization literally comes to naught during National Immunization Days, when all vaccinators are entrusted with the additional responsibility of covering 150–200 children per day, door-marking, record keeping in tally-sheets, and locating and marking missing children [24]. Coverage of vaccination services requires a rational re-deployment of vaccinators, and taskshifting to community-based service providers e.g. lady health workers (LHWs) and community midwives for covering their catchment areas. Vaccinators would thus be able to focus on areas not covered by any workers [25]. Involvement of the private sector and NGO outlets is also one of the solutions, but at present there is no policy in EPI on formal engagement with

Interrupted supply of vaccines has been reported from time to time. Delays in forecasting, procurement, storage, and distribution to the provinces, districts and to the "last mile" (i.e. the hardest to reach segments of the population) have suffered in the past because of unduly tedious procedures [13]. Inadequate maintenance of cold chain is another issue reported in the literature. Power outages are frequent and there is no electricity back up at many places. EPI has state of the art cold chain for vaccine storage and transport; however, its maintenance has been a long-standing issue, particularly in rural remote areas where program monitoring is also weak [26]. Alternative solutions such as solar energy ought to be tried as a backup for

organizations (NGOs) can potentially improve the HR performance [23].
